Indoor Air 2009; 19: 75–82 Ó 2008 The Authors

www.blackwellpublishing.com/ina Journal compilation Ó Blackwell Munksgaard 2008

Printed in Singapore. All rights reserved
INDOOR AIR
doi:10.1111/j.1600-0668.2008.00563.x

Indoor carbon monoxide and PM2.5 concentrations by cooking

fuels in Pakistan

Abstract In developing countries biomass combustion is a frequently used source A. R. Siddiqui1,2, K. Lee1,3,
of domestic energy and may cause indoor air pollution. Carbon monoxide (CO) D. Bennett1, X. Yang1, K. H. Brown4,
and particulate matter with an aerodynamic diameter of 2.5 lm or less (PM2.5) Z. A. Bhutta5, E. B. Gold1
were measured in kitchens using wood or natural gas (NG) in a semi-rural
1
community in Pakistan. Daytime CO and PM2.5 levels were measured for eight Department of Public Health Sciences, University of
continuous hours in 51 wood and 44 NG users from December 2005 to April California at Davis, CA, USA, 2Department of
2006. The laser photometer PM2.5 (Dustrak, TSI) was calibrated for field Community Health Sciences, Aga Khan University,
conditions and PM2.5 measurements were reduced by a factor of 2.77. CO was Karachi, Pakistan, 3Graduate School of Public Health
and Institute of Health and Environment, Seoul
measured by an electrochemical monitor (Model T15v, Langan). The arithmetic
National University, Seoul, Korea, 4Program in
mean for daytime CO concentration was 29.4 ppm in wood users; significantly International Nutrition, University of California at Davis,
higher than 7.5 ppm in NG users (P < 0.001). The arithmetic mean for daytime CA, USA, 5Department of Pediatrics, Aga Khan
PM2.5 concentrations was 2.74 mg/m3 in wood users; significantly higher than University, Karachi, Pakistan
0.38 mg/m3 in NG users (P < 0.001). Higher peak levels of CO and PM2.5 were
also observed in wood users. Time spent in the kitchen during fuel burning was
significantly related to increasing CO and PM2.5 concentrations in wood users. Key words: Indoor air quality; Biomass combustion;
These findings suggest that cooking with wood fuel may lead to hazardous Developing country; Wood burning; Kitchen.
concentrations of CO and PM2.5. K. Lee
Graduate School of Public Health
Seoul National University
28 Yeongun-dong Jongro-gu
Seoul 110-460
Korea
Tel.: 82 2 740 8881
Fax: 82 2 745 9104
e-mail: cleanair@snu.ac.kr

Received for review 2 April 2008. Accepted for

publication 10 July 2008.
Ó Indoor Air (2008)

Practical Implications
Biomass combustion is frequently used in developing countries for cooking. This study showed very high level of air
pollution in kitchens using wood as the cooking fuel. Many people, especially women and children, are vulnerable to
exposure to very high levels of air pollutants as they spend time in the kitchen during cooking hours.

ulate matter (PM), polycyclic aromatic hydrocarbons,

Introduction
Biomass, such as wood, crop residues and dung are
used as cooking fuels by half of the worldÕs population;
three-fourth of such use occurs in developing countries
(Bruce et al., 2000). Biomass provides 70% of Paki-
stanÕs domestic sector energy and 53% of the biomass
energy is from wood (IUCN, 2003; Rehfuess et al.,
2006). Typical traditional biomass stoves can divert up
to 38% of fuel carbon into products of incomplete
combustion, including carbon monoxide (CO), partic-
along with releasing other toxic substances, including
nitric oxides, sulfur dioxide, and formaldehyde (Bruce
et al., 2000; Smith et al., 2000; Zhang and Smith,
2005).
Indoor air pollution from biomass fuel is the 8th most
important risk factor, responsible for 2.7% of the
global burden of disease (Smith et al., 2004). In high-
mortality developing countries, indoor smoke is respon-
sible for an estimated 3.7% of the overall disease
burden, making it the most lethal killer after malnutri-

75
Siddiqui et al.
tion, unsafe sex and lack of safe water, and sanitation
(Smith et al., 2004). The overall disease burden (Dis-
ability-Adjusted Life Years or DALYs) from indoor air
pollution in developing countries is more than five times
greater than the burden from outdoor air pollution
(Smith et al., 2004). Women and young children in
developing countries are particularly at risk of being
exposed to high concentration of indoor air pollutants,
because they spend the most time in the home during
fuel burning. Well-established health outcomes related
to indoor biomass burning include acute lower respira-
tory infections in children up to 5 years and chronic
obstructive lung disease in adults (Bruce et al., 2000).
Evidence is emerging that exposure to biomass burning
increases the risk of other conditions, such as tubercu-
losis, asthma, cataracts, low birth weight, and peri-natal
mortality (Bruce et al., 2000).
Increased indoor air pollution can occur because of
poor air mixing in the stove, especially when the stove
is not well-ventilated, with concentrations of CO and
PM often exceeding the ambient air quality standards
set by the US. Environmental Protection Agency
(EPA) and World Health Organization (WHO) stan-
dards for CO and EPA standard for PM <2.5 lm
aerodynamic diameter (PM2.5; von Schirnding et al.,
2002). Various studies for wood burning have found
high indoor levels of CO and PM2.5 in Guatemala
(Bruce et al., 2000; Naeher et al., 2001), CO in rural
Pakistan (Khushk et al., 2005), PM2.5 in rural Mexico
(Brauer et al., 1996), PM <10 lm aerodynamic dia-
meter (PM10) in rural Bolivia (Albalak et al., 1999),
suspended particle matter in India (Lohdi and Zain-
al-Abdin, 1999), and respirable particulate (50% cut-
off at 4 lm) levels in India (Balakrishnan et al., 2004).
The present study was a part of a larger study that
evaluated prenatal exposure to cooking with wood fuel
and adverse infant birth outcomes in a cohort of
women living in southern semi-rural areas of Pakistan
(Siddiqui et al., 2008). The purpose of this study was to
measure and compare daytime indoor air concentra-
tions of CO and PM2.5 in kitchens where wood or
natural gas (NG) was used as cooking fuel. Addition-
ally, the associations of housing characteristics and
cooking patterns with indoor CO and PM2.5 concen-
trations were determined.
Methods
Study setting
This study was conducted in a semi-rural coastal area,
Rehri Goth, located 50 km south-east from Karachi,
Pakistan with a total population of 14,000. The region
has a relatively mild climate. The temperature is in the
range of 25–31°C in the winter months (November
through March). The level of precipitation is low for
most of the year. However, because of proximity to the
76
sea, humidity levels usually remain high throughout the
year. The area lacked transportation, education, and
health services (IUCN, 2003). Reported use of wood as
cooking fuel in this population was 50% in the year
2003. Wood burning stoves in this region are generally
based on a three rock system (placing three rocks on
the ground) and there were no formal structures or
ventilation for the cooking system. More than 40% of
the areaÕs population had a monthly income of less
than Rs. 625/capita ( US $10); 60% of men and 90%
of women had not received any formal schooling or
education; the main occupation of the men was fishing,
and women did not work outside the home (IUCN,
2003). The study region may not represent the rest of
semi-rural Pakistan. The selection of the region was in
part because of an existing cohort.
Study sample participants
Participants belonged to an established cohort of
women (n = 806) who delivered a singleton live infant
during 2000–02. Data for those births were recorded by
a surveillance program of Aga Khan University during
this period. In 2004, a survey administered to all women
documented the type of cooking fuel and monthly
income. Participants in the cohort were stratified by
type of fuel, wood or NG, and by a median monthly
income of less than or equal to or greater than Rs. 3000
(US $50) per household. We randomly selected 120
women (15% of the cohort), 30 in each of the two
income groups and in the two fuel groups, 19 of whom
(eight with wood and 11 with NG) refused to partic-
ipate in air sampling measurements, and six of whom
(one with wood and five with NG) could not be sampled
due to technical and logistic difficulties. It is noted that
actual proportion of NG users is small among this
population. NG users were heavily selected.
Participants consenting (n = 95) for air sampling
did not differ from those who refused (n = 19) in
frequency of cooking per day; but differed by having
longer fuel burning duration (P < 0.04), and more
persons for whom food was cooked (P < 0.02). Signed
informed consent in the local language was obtained
for interviews and air sampling procedures. The study
protocol was approved by the institutional review
board at UC Davis and the Ethics Review Committee
of Aga Khan University, Pakistan.
Study design
In a survey conducted from January through October
2005, an interviewer-administered questionnaire ascer-
tained the type of housing, demographic and socio-
economic characteristics, reproductive history, and
cooking related and other lifestyle factors from the
participants. Daytime CO and PM2.5 were measured in
cooking areas over 8 h in each house (n = 95),

between December 2005 and April 2006. The winter
period was selected based on the assumption of higher
concentrations in winter because of more limited
ventilation. Air sampling started in the morning
between 8:30 and 9:30 AM and ended around 5:00 PM.
The period of sampling included the majority of
cooking activities during the day. Participants were
asked in an interview at the end of the day about the
fuel burning duration, time spent in the kitchen during
fuel burning, and time spent in activities outside the
kitchen.
In the months of December and January, a similar
number of houses were sampled with wood (n = 10)
and NG (n = 12); but more wood users (n = 18) than
NG users (n = 3) were sampled in February due to the
calibration study in wood users of the Dustrak
(described below). Correspondingly, more NG users
were sampled in the months of March (10 wood and 14
NG users) and April (one wood and eight NG users).
Air concentration measurements
An electrochemical CO monitor (Langan Model T15v;
Langan Products Inc., San Francisco, CA, USA) and
an aerosol spectrometer for PM2.5 (Dustrak Model
8520; TSI, Shoreview, MN, USA) measured daytime
concentrations of CO and PM2.5, respectively. The
monitors were placed in the cooking area at breathing
height (about five feet above the ground), secured on a
flat surface 0.5–1 m from edge of the stove. Data were
stored in an internal datalogger and were downloaded
daily, using Spectrum V3.7d for CO and TSI Trak pro
3.41 for PM2.5.
The Dustrak was calibrated against Arizona Test
Dust by the manufacture. Since this test dust has
different characteristics than biomass PM, the monitor
was calibrated against a gravimetric sampler (SKC
PEM sampler 761–203A; SKC, Eighty Four, PA,
USA) in a subset of participantÕs kitchens. The PEM
sampler was operated at a flow rate of 4 l/min using a
battery operated SKC pump (Model 224-44XR). PM2.5
samples were collected on a 37 mm Teflon filter with
2.0 lm pore size. The filters were weighed using a
microbalance (Model CAHN-28; CAHN Instruments,
Cerrito, CA, USA). The Dustrak and gravimetric
sampler were co-located within one foot in 15 wood
users during February–March 2006. Data for a total of
30 such paired measurements were collected.
Correlation of the PM2.5 measurements from the
Dustrak and gravimetric sample was determined using
24 pairs. Five Dustrak measurements exceeded maxi-
mum detection limit of 100 mg/m3 and one filter
appeared damaged. Dustrak readings overestimated
the gravimetric mass concentration by a factor of 2.77.
The correlation coefficient (r) between the Dustrak and
gravimetric sampler was 0.87 (Figure 1). This compar-
ison may have been affected by the high mass
Indoor CO and PM2.5 concentrations by cooking fuels
5
PM2.5 by gravimetric method (mg/m3)
4
y = 0.361x
R 2 = 0.752
3
2
1
0
0 2 4 6 8 10 12 14
PM2.5 by DUSTRAK (mg/m3)
Fig. 1 Association between gravimetric concentration for PM2.5
and Dustrak measurement in wood user
concentration. The Dustrak requires inlet cleaning
after 30 h mg/m3. However, several samples exceeded
the level, which may have caused some variations in the
comparison. In this study, all values <100 mg/m3
assessed by the Dustrak were reduced by this calibra-
tion factor of 2.77 and all Dustrak readings above
100 mg/m3 were fixed to 100 mg/m3 before the correc-
tion.
Data analyses
Carbon monoxide and PM2.5 concentrations over 8-h
were time averaged for each house. Using the time-
averaged concentrations, the arithmetic means were
calculated for NG and wood burning homes for both
CO and PM2.5. Maximum 1 h arithmetic means were
also calculated for each house for both CO and PM2.5.
Data for different types of cooking areas were
separated into two groups; those with a separate
kitchen and those with other cooking areas (living
room, corridor under a roof, and any space in house).
Similarly, the number of windows in the kitchen was
dichotomized as none or one or more. We created an
ordinal variable for the 5 months from December 2005
to April 2006 to incorporate variation in pattern of
stove use or any potential changes related to cooking
and heating habits with changes in weather.
Continuous variables were compared using paramet-
ric (StudentÕs t-test) and non-parametric statistical tests
(Wilcoxon sign rank, Mann–Whitney or Kruskal–
Wallis tests) of significance, depending on the distri-
bution. Categorical variables were compared by a Chi
square statistical test of significance and a P value
of <0.05 was taken as the level of significance.
Geometric means of CO and PM2.5 were evaluated
for associations with cooking related variables. Multi-
ple linear regression modeling was performed to study
the determinants of log transformed geometric means
of CO and PM2.5 in each fuel group separately. A series
of linear regression models were developed to evaluate
77
Siddiqui et al.

the factors operating at the household level that might
have been responsible for increasing the concentrations
of CO and PM2.5 within each fuel group. The models
for CO or PM2.5 were examined after including the
variables with P values of <0.20 in the bivariate
analyses and retained, with those that improved the fit
of the model. These multivariable models were
adjusted for the month of sampling with the assump-
tion that use of cooking fuel and types of food cooked
differed by month. Some of the variables did not meet
the definition of confounding but were retained for face
validity.
Results
Characteristics of study participants
Participants did not differ by type of fuel for mean age,
monthly income, family and house size, smoking
habits, or having a separate kitchen for cooking
(Table 1). More wood users lived in houses made of
a mix of straw and bricks than NG users (P < 0.001),
with a fewer of them having a window in the kitchen
(P < 0.08; Table 1). While comparisons indicated
better home construction for NG users, these differ-
ences were not reflected in differences in socio-eco-
nomic status. In contrast, a higher fraction of NG users
reported using the stove in the past to heat the house
(P = 0.04). Mean fuel burning duration and time
spent by the participant in the kitchen during fuel
burning were significantly longer in wood users than
were 14% in NG and 18% in wood users. They were
not significantly different.
Mean concentrations by fuel group
Carbon monoxide and PM2.5 levels differed signifi-
cantly (Mann–Whitney test, P < 0.05) in the two fuel
types across multiple points of the distribution, includ-
ing median, mean, and peak levels. No significant
differences were observed by income for CO and PM2.5
within each fuel group by parametric (StudentÕs t-test)
or non-parametric statistical tests of significance
(Kruskal–Wallace test). The distributions of the time-
averaged concentrations of CO and PM2.5 by fuel
type and income group are displayed in Figure 2a,b
respectively.
The arithmetic means of the 8 h time-weighted CO
concentrations were 29.5 ppm (s.d. = 16.2 ppm) in
wood users and 7.5 ppm (s.d. = 4.4 ppm) in NG users,
while the geometric mean was 24.2 ppm (g.s.d. = 2.02)
in wood users and 6.5 ppm (g.s.d. = 1.7) in NG users
(Table 2). In wood users, 88% had a time-averaged CO
(a) CO
50.0
40.0
30.0
ppm

NG users (P = 0.007). Smoking rates of the spouse

20.0

10.0

Table 1 Demographic and socioeconomic characteristics of participants by type of fuel 0.0

Natural gas Wood ian ian ian dia

n
m ed me
d ed me
(n = 44) (n = 51) e< Ã m Ã
e¡ e< e¡
om om om om
inc inc nc inc
NG di od
Variable Mean (s.d.) Mean (s.d.) NG Wo
o
Wo

Age (years) 27.9 (4.7) 28.6 (5.9) (b)

Number of rooms on house 2.2 (1.4) 2.1 (1.6) 8.0 PM2.5
Number of persons living in house 8.6 (4.1) 8.1 (4.0)
Crowding index (no. of persons/no. of rooms) 4.6 (2.3) 5.0 (2.2)
Monthly income (US $) 52 (22) 48 (18) 6.0
Fuel burning duration (min/day)** 215 (52) 246 (57)
mg/m3

ParticipantÕs time spent in kitchen during fuel 199 (82) 241 (67)
burning on sampling day (min/day)** 4.0

Percent
2.0

House made of straw or bricks** 61 96

Cooking done in a separate kitchen 80 86
0.0
Frequency of cooking 3–4 times/day 61 78
No windows in kitchen 46 67 ian ian ian n
ed ed ed dia
m m m me
Stove used to heat the house in the past* 32 14 e< e≤ e< ≤
om om om me
Spousal literacy status: not literate 77 92 inc inc inc nc
o
NG NG od o di
Spousal occupation; fisherman 80 94 Wo Wo
Presence of smoker in home 32 37
Fig. 2 Box plots of (a) carbon monoxide (CO) and (b) PM2.5 by
*P < 0.05, **P < 0.01. fuel type and median income

78
 Indoor CO and PM2.5 concentrations by cooking fuels

Table 2 Summary statistics for CO and PM2.5 in wood users (n = 51) and NG users (n = 44)

CO (ppm) PM2.5 (mg/m3)

Difference Difference
between between
Fuel type Mean s.d. means 95% CI Mean s.d. means 95% CI

Arithmetic mean
Wood 29.5 16.2 21.9 17.3, 26.7 2.74 2.06 2.36 1.70, 2.98
NG 7.5 4.4 0.38 0.39
Average of 1 h maximum
Wood 72.4 32.6 54.2 44.6, 63.6 9.62 6.74 7.6 5.58, 9.64
NG 18.2 10.6 2.0 2.5

CO, carbon monoxide; PM, particulate matter; NG, natural gas.

concentration of more than 9 ppm (the US EPA (a) 160 120

NAAQS for 8 h CO), but only 27% of NG users 140

CO 100
exceeded this level. Sixty-one percent of the wood users 120 PM2.5
(n = 31) but none of the NG users had CO concentra- 80

PM2.5 (mg/m3)
100
tions above the WHO 8 h guideline of 25 ppm.

CO (ppm)
The arithmetic means of the PM2.5 time-averaged 80 60

concentrations were 2.74 mg/m3 (s.d. = 2.1 mg/m3) in 60

40
wood users and 0.38 mg/m3 (s.d. = 0.39 mg/m3) in 40
NG users (Table 2). The geometric means were 20
20
1.79 mg/m3 (g.s.d. = 3.0) in wood users and
0.24 mg/m3 (g.s.d. = 2.7) in NG users. 0
9:36 10:48 12:00 13:12 14:24 15:36 16:48
0

Arithmetic mean concentrations of CO and PM2.5

were significantly correlated. The Spearman correla- (b) 60 1.2

tion coefficient was 0.72 (P < 0.01) for wood users and 50 CO 1
Carbon monoxide (ppm)

0.37 (P < 0.05) for NG users. Typical temporal PM2.5

0.8

PM2.5 (mg/m3)
40
profiles of CO and PM2.5 in wood users and NG users
are displayed in Figure 3. CO and PM2.5 increased 30 0.6
simultaneously in wood users, while the PM2.5 increase 20 0.4
occurred after the CO increase in NG users. The
delayed PM2.5 increase in NG users may be due to 10 0.2

burning of some foods. The levels decreased rapidly in 0 0

NG users but CO and PM2.5 decreased over a long time 9:36 10:48 12:00 13:12 14:24 15:36 16:48 18:00

in wood users.
Peak concentrations by fuel group
Wood users showed higher peak levels of CO, with an
arithmetic mean of 87.6 ppm (s.d. = 27.5 ppm) com-
pared with 44.3 ppm (s.d. = 28.1 ppm) in NG users.
Similarly, peak levels of PM2.5 had an arithmetic mean of
28.1 mg/m3 (s.d. = 11.3 mg/m3) in wood users com-
pared with 9.0 mg/m3 (s.d. = 10.0 mg/m3) in NG users.
Considering the distribution of the maximum 1 h time-
averaged concentration for each home, the arithmetic
means for CO were 72.4 ppm (s.d. = 32.6 ppm) in
wood users and 18.2 ppm (s.d. = 10.6 ppm) in NG
users (Table 2). The EPA NAAQS standard for 1 h CO
(35 ppm) was exceeded in 80% of wood users (41/51)
compared with only 7% (3/44) of NG users. The max-
imum 1 h concentrations for PM2.5 were 9.62 mg/m3
(s.d. = 6.74 mg/m3) in wood users and 2.0 mg/m3
(s.d. = 2.5 mg/m3) in NG users (Table 2).
Fig. 3 Typical temporal profiles of carbon monoxide (CO) and
PM2.5 levels. (a) Wood user and (b) Natural gas (NG) user
Findings from multiple linear regression modeling
Several housing characteristics and cooking-related
characteristics were associated with CO and PM2.5
levels (Table 3). CO and PM2.5 concentrations were
not significantly associated with house construction or
presence of windows in kitchen. Among NG users, CO
concentrations in homes without a separate kitchen
were significantly higher (P < 0.03) but this was not
the case for PM2.5 concentrations (P < 0.17; Table 3).
For wood users, when more than one person was
cooking in the kitchen, PM2.5 levels tended to be
higher, but not significantly (P < 0.08). PM2.5 levels in
wood users gradually and significantly increased with
both increasing fuel burning duration (P < 0.04) and
time spent in the kitchen (P < 0.023; Table 3).

79
Siddiqui et al.

Table 3 Indoor air concentrations for CO and PM2.5 by type of fuel and cooking habits of PM2.5 level was lower in a separate kitchen, but the
participants
association was not significant (Table 5).
CO
(ppm) PM2.5 (mg/m3)
NG, Wood, Discussion
Variables n = 44 n = 51 NG (s.d.) Wood (s.d.) NG (s.d.) Wood (s.d.)
Indoor concentrations of CO and PM2.5 were signifi-
Separate kitchen cantly higher in wood users compared with NG users,
No 9 7 7.5 (6.3)* 15.9 (9.4) 0.04 (0.01) 0.18 (0.19) and a similar difference has been reported in studies
Yes 35 44 4.9 (1.7) 20.3 (12.4) 0.03 (0.02) 0.15 (0.15) from Guatemala and Mexico (Brauer et al., 1996;
Stove to heat
No 14 7 5.6 (3.7) 20.9 (12.4) 0.03 (0.02) 0.16 (0.17)
Naeher et al., 2000b). The difference was mainly
Yes 30 44 5.0 (2.1) 12.5 (6.1) 0.03 (0.01) 0.13 (0.07) explained by higher emission rates from wood com-
No. of persons cook in kitchen bustion. Use of wood as cooking fuel has been reported
1 30 40 5.1 (3.3) 19.8 (12.8) 0.03 (0.01) 0.16 (0.17) to be the main determinant of increasing concentra-
>1 14 11 6.0 (3.2) 19.3 (9.6) 0.03 (0.03) 0.14 (0.10)
Fuel burning time in min
tions of indoor air pollutants compared with cleaner
<210 14 9 4.9 (2.2) 18.2 (9.9) 0.02 (0.01) 0.09 (0.04)* fuels, such as electricity or NG (Bruce et al., 2000,
210–235 12 12 5.9 (4.7) 18.4 (10.1) 0.03 (0.02) 0.10 (0.08) 2004; Khushk et al., 2005; Naeher et al., 2000a).
236–270 12 9 5.6 (3.5) 15.6 (10.6) 0.03 (0.02) 0.13 (0.11) Direct comparisons of levels of PM2.5 and CO
>270 6 21 5.1 (1.4) 22.9 (14.3) 0.03 (0.02) 0.22 (0.21)
between this study and studies conducted in other
Time spent in kitchen in min
<195 15 8 5.3 (2.0) 17.8 (11.4) 0.02 (0.02) 0.09 (0.05)* countries and with other burning and cooking tech-
195–235 11 13 5.7 (5.1) 17.1 (9.7) 0.02 (0.01) 0.09 (0.08) niques are difficult due to variations monitoring
236–270 12 9 5.4 (3.5) 15.4 (11.4) 0.03 (0.02) 0.13 (0.11) techniques and sample duration. This study measured
>270 6 21 4.9 (1.6) 23.9 (13.4) 0.03 (0.02) 0.23 (0.21 day time 8-h levels of CO and PM2.5. As expected, our
CO, carbon monoxide; PM, particulate matter; NG, natural gas.
8-h concentrations were higher than studies measuring
*P < 0.05. for longer time periods, between 22 and 24 h, likely
because of the inclusion of more non-burning time over
the measurement period in the longer studies (Bruce
In wood users, CO level was positively associated et al., 2004; Naeher et al., 2000a,b). Studies measuring
with time spent by the participant in the kitchen during PM10 instead of PM2.5 found higher levels as expected
fuel burning after adjusting for confounding variables (Albalak et al., 1999; Ezzati et al., 2000). Direct
in multiple linear regression models (Table 4). In NG comparisons are possible with one study from Mexico
users, CO levels were significantly associated with which reported arithmetic mean PM2.5 levels of
number of persons cooking in the same kitchen and 0.55 mg/m3 for wood users and 0.069 mg/m3 in gas
sampling month (Table 4). Although the association users measured over a range of 6–11 h with a mean
was not significant, CO levels were positively associ- sampling time of 9 h (Brauer et al., 1996).
ated with fuel burning duration and negatively associ- Other studies measured short time periods (<1 h)
ated with use of separate kitchen. In wood users, the during cooking (Khushk et al., 2005; McCracken and
PM2.5 level was significantly associated with time spent Smith, 1998). We would expect these measurements to
in the kitchen by the participant during fuel burning be greater than our 8 h average levels which include
(Table 5). In NG users, the PM2.5 level was signifi- non-cooking time. They would also be expected to be
cantly associated with sampling month (Table 5). The less than our 1-h peak concentrations as the other

Table 4 Multiple linear regression models for concentration of carbon monoxide (log transformed geometric mean) in NG users and wood users

NG (n = 44) Wood (n = 51)

Variables Beta (s.e.) 95% CI P Beta (s.e.) 95% CI P

Time spent in kitchen during fuel burning in min/day 0.005 (0.001) 0.002, 0.007 0.002
Kitchen type: )0.29 (0.14) )0.58, 0.001 0.051
separate = 1
other = 0
Fuel burning time in min/day 0.002 (0.001) 0.00, 0.005 0.06
No. of persons cooking in same kitchen 0.27 (0.12) 0.01, 0.53 0.037
1=0
>1 = 1
Sampling montha 0.11 (0.04) 0.03, 0.19 0.008
Constant 1.02 (0.30) 0.41, 1.64 0.002 0.811 (0.67) )0.54, 2.1 0.23

NG, natural gas.

a
Sampling month increases from December 2005 to April 2006.

80

Table 5 Multiple linear regression models for concentration of PM2.5 (log transformed geometric mean) in NG users and wood users
NG (n = 44)
Variables Beta (s.e.)
Time spent in kitchen in min/day
during fuel burning times
Kitchen type: )0.36 (0.18)
separate = 1
other = 0
Sampling montha )0.13 (0.05)
Constant )2.97 (0.18)
NG, natural gas; PM, particulate matter.
a
Sampling month increases from December 2005 to April 2006.
studies did not necessarily capture the peak concentra-
tions. Instantaneous readings for CO were measured in
kitchens during cooking in a study of two villages of
Sindh in southern Pakistan, in traditional stoves and
smoke-free stoves (Khushk et al., 2005). The mean CO
level of instantaneous measurements was 28.5 ppm
(s.d. = 5.7 ppm) in wood users in rural Pakistani
kitchens, comparable to our 8-h arithmetic mean of
29.4 ppm. Concentrations measured in this study were
higher than measurements in wood users in Guatemala
during water boiling tests and averaged across five
houses (arithmetic mean of 11.8 ppm, s.d. = 3.28
ppm) and comparable to cooking (arithmetic mean
of 69.1 ppm, s.d. = 18.8 ppm) in the same homes
(McCracken and Smith, 1998).
The observed peak levels for PM2.5 in our study in
wood users were higher than the levels observed for the
24 h average of respirable particulates in rural India
(Balakrishnan et al., 2004), for the averages of 6–11 h
of PM2.5 in Mexico (Brauer et al., 1996), and spot
measurements of PM2.5 in Guatemala (Naeher et al.,
2000a,b) in wood or biomass users. In our study, the
1-h maximum mean for PM2.5 levels was 9.62 mg/m3 in
wood users. The study from Mexico reported a mean
of peak levels for PM2.5 of 2.0 mg/m3 (Brauer et al.,
1996). The study in Guatemala made measurements for
only a few minutes during cooking and reported mean
PM2.5 levels of 5.31 mg/m3 (s.d. = 4.75 mg/m3; Nae-
her et al., 2000b). Lower concentrations of RSP (0.5–
2.0 mg/m3) were reported during cooking for biomass
users in India but could have been due to less intensive
cooking as suggested by the authors (Balakrishnan
et al., 2004). These differences from other studies could
be due to differences in the frequency of fuel use, type
of food cooked, type of wood/biomass burned, cook-
ing area used and degree of ventilation in the kitchen.
The positive relationship we found between time spent
cooking and increasing concentrations of PM2.5 in wood
users is plausible. Increased PM2.5 concentrations were
significantly associated with fuel burning duration and
the participantÕs time spent in the kitchen during fuel
burning in wood users. PM2.5 emissions with wood use
can vary when wood is added, stirred, removed, a pot is
Indoor CO and PM2.5 concentrations by cooking fuels
Wood (n = 51)
95% CI P Beta (s.e.) 95% CI P
0.005 (0.002) 0.001, 0.009 0.028
)0.74, 0.01 0.059
)0.23, )0.03 0.011
)3.3, )2.5 0.00 )3.42 (0.51) )4.4, )2.3 0.00
placed, or when food is stirred (Ezzati et al., 2000).
Wood smoldering (without flames) generates smoke
continuously (Ezzati et al., 2000); hence, the pattern of
wood use can explain the relationship of the participantsÕ
time spent during fuel burning with increasing concen-
trations of PM2.5. Cooking habits and cooking methods
give rise to high emissions and high peaks of CO and
PM2.5 that occur during cooking (Ezzati et al., 2000) and
diffuse rapidly into living spaces (Dasgupta et al., 2006).
The mean cooking duration (4 h/day) in wood users
is comparable to that reported from other studies;
5 h/day from Guatemala (McCracken and Smith, 1998)
and 6.5 h/day from Mexico (Brauer et al., 1996). In our
study, NG users spent an average of 3.5 h/day in
cooking, which was longer than the reported mean
duration of 2 h from Mexico (Brauer et al., 1996).
Personal exposure is significantly increased by longer
cooking hours (Ezzati et al., 2000).
Time-averaged concentrations of CO and PM2.5 were
significantly correlated, especially in wood users (Spear-
man correlation coefficient of 0.72). This correlation has
been consistently observed in many studies for wood,
with a value of 0.71 in Costa Rica (Park and Lee, 2003)
and 0.92 in Guatemala; implying that CO was a good
proxy for PM2.5 in homes using wood fuel. We found
less significant correlations for NG than wood users, as
has been shown elsewhere (Naeher et al., 2001),
strengthening the fact that using CO as a proxy for
PM2.5 exposure is not as effective for gas stove users.
Our study had several major strengths. First, we
measured concentrations of CO and PM inside the
kitchen where the risk of exposure to air pollutants was
highest. Second, we calibrated our measurements of
PM2.5 by measuring the mass concentration of fine
particles, as Dustrak measurements of PM2.5 may
overestimate the mass concentrations of PM2.5. Third,
our study sample selection was based on a stratified
random sub-sample of a cohort of women. However, the
difficulty of conducting measurements of indoor air
pollutants in remote localities limited our ability to
conduct measurements in a large sub-sample of our
cohort of previously pregnant women. The small sample
size in each of the four strata of sampled houses may
81
Siddiqui et al.

have resulted in inadequate statistical power to find
some significant associations. In addition, placing the
sampler in the breathing zone of those likely to be
exposed may not have been uniform in all houses
because of the constraint that the spaces were often small
and that participants required access to their stoves;
however, the variation in this placement among parti-
cipating households is likely to have been random.
This study found that wood users were less-educated,
lived in houses made of a straw or a mix of straw and
bricks with inadequately ventilated kitchens, had a
longer duration of fuel burning, and cooked for longer
duration during fuel burning. Such differences in
populations by fuel type may enhance the vulnerability
of females and perhaps children to high air pollutant
levels which could lead to adverse health effects. This
study demonstrated that women involved in cooking
with biomass are potentially vulnerable to exposure to
high concentrations of CO and PM2.5. Considering the
significant number of women in developing countries,
this is a critical worldwide public health issue.
Our findings can be useful for understanding potential
health effects from the exposure and intervention studies
in such settings. Changes in fuel type, cooking behavior,
and kitchen practices may bring about the reduction of
indoor air pollutants emitted by cooking fuels.
Acknowledgements
We acknowledge our participants and field staff. We
are grateful for the support from Department of
Biomedical Engineering Aga Khan University for
technical advice regarding maintenance of air sample
instruments. The study was funded by NIH (5R03
ES13159-2). This project was partially supported by
NIH Research Grant # D43 TW01267 funded by the
Fogarty International Center and the National Insti-
tute of Child Health and Human Development.

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